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Requirements and Study Design for the Next Proton FLASH Clinical Trials: an International Multidisciplinary Delphi
Yvonne L B Klaver1, Mischa S Hoogeman2, Q Richard Lu3
1HollandPTC, Delft, The Netherlands; Department of Radiotherapy, Leiden University Medical Center, Leiden, The Netherlands.
Proton FLASH (pFLASH) irradiation shows promise for sparing normal tissues while controlling tumors. Expert consensus recommends preclinical validation and toxicity reduction as primary endpoints for future clinical trials, with specific patient and setting guidelines.
Area of Science:
- Oncology
- Radiation Oncology
- Medical Physics
Background:
- The FLASH effect, utilizing ultra-high dose-rate irradiation, demonstrates normal tissue sparing and tumor control in preclinical models.
- Biological mechanisms of the FLASH effect remain unclear, necessitating clinical investigation.
- Proton FLASH (pFLASH) irradiation requires established prerequisites for clinical trials.
Purpose of the Study:
- To establish expert consensus on prerequisites, study design, and endpoints for clinical trials investigating proton FLASH (pFLASH) irradiation.
- To guide the development of future clinical trials exploring the potential of pFLASH.
Main Methods:
- Utilized Delphi methodology with an international expert panel (21 clinicians, physicists, biologists).
- Two rounds of online questionnaire voting using a 5-point Likert scale to achieve consensus.
- Predefined inclusion criteria and consensus definitions were employed.
Main Results:
- Preclinical in vivo demonstration of the FLASH effect in normal tissues and tumors is essential before clinical trials.
- Recommended adult patients with >1-year survival (palliative) or oligometastatic disease (ablative).
- Advised single treatment modality with toxicity reduction as the primary endpoint; consensus not reached on multiple beams/fractions.
Conclusions:
- Further data on fractionation and multiple beam planning are needed for pFLASH.
- This expert consensus provides a roadmap for designing future pFLASH clinical trials.
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